An Evolution in the Use of Radiation

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2.7 x 2.2 cm (pineal)

1.9 x 1.5 x 1.2 cm (suprasellar tumor)

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Case Presentation MN

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Case Presentation MN

Laboratory evaluation revealed panhypopituitarism, nml AFP and beta-HCG in both serum and CSF.

Management:

5/9/2008 placement of EVD

5/14/2008 craniotomy with biopsy – non-diagnostic

5/16/08 VP shunt placement

5/29/08 Second craniotomy with biopsy-non-diagnostic

Treatment of panhypopituitarism treated with DDAVP, hydrocortisone, and levothyroxine

6/27/2008 Endoscopic biopsy of third ventricle and pineal region tumor.

Findings – small amount of tumor noted to be coating the floor of the third ventricle as well as a fluffy tumor in the posterior third ventricle. Biopsies were obtained.

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Case Presentation MN

Pineal Tumor biopsy – Pathology

Lymphohistiocytic inflammation with rare embedded OCT 3 / 4 (+) atypical cells. Most compatible with germinoma.

Treatment Plan: COG ACNS 0232 4 cycles of carbo/etoposide plan individualized to receive 4 cycles of carboplatin and etoposide) 7/31/08 - 10/10/08. Followed by whole ventricular radiation therapy to 24 Gy with tumor boost to 30 Gy.

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Radiation and Germinomas

Germ Cell Tumors

3-5% primary brain tumors in children and young adults

50-60% Germinomas

Most common in male children ages 10-20 and arise in midline locations such as pineal and suprasellar regions

Traditional radiation for primary CNS Germinoma’s.

Large Volume/high dose radiotherapy.

CSI 30-36Gy

15 Gy boost to primary tumor.

10 year OS >80%

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CSI rational

Sung et al 1978 (pre-CT era)

77 patients

> 10% percent risk of subarachnoid dissemination

Haddock et al (Mayo experience) reported on 25 patients who received RT to 44 Gy without full CSI. 36% spine relapses were reported.

5 year survival was still 90%

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CSI

CSI has been the gold standard for patients even with local disease.

Harmful effects of CSI on neurocognitive development extrapolated from the literature on PNET.

The aim now becomes focused on limiting treatment related side effects.

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Chemotherapy Alone

“International protocol” Balcameda et al JCO 1996

CDDP, VP-16, bleomycin x 4 cycles followed by imaging eval